Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2020 Nov;73(5):1082-1091.
doi: 10.1016/j.jhep.2020.04.024. Epub 2020 Apr 24.

Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS

Jonel Trebicka  1 , Wenyi Gu  2 , Luis Ibáñez-Samaniego  3 , Virginia Hernández-Gea  4 , Carla Pitarch  5 , Elisabet Garcia  5 , Bogdan Procopet  6 , Álvaro Giráldez  7 , Lucio Amitrano  8 , Candid Villanueva  9 , Dominique Thabut  10 , Gilberto Silva-Junior  11 , Javier Martinez  12 , Joan Genescà  13 , Cristophe Bureau  14 , Elba Llop  15 , Wim Laleman  16 , Jose Maria Palazon  17 , Jose Castellote  18 , Susanag Rodrigues  19 , Liselotte Gluud  20 , Carlos Noronha Ferreira  21 , Rafael Barcelo  22 , Nuria Cañete  23 , Manuel Rodríguez  24 , Arnulf Ferlitsch  25 , Jose Luis Mundi  26 , Henning Gronbaek  27 , Manuel Hernández-Guerra  28 , Romano Sassatelli  29 , Alessandra Dell'Era  30 , Marco Senzolo  31 , Juan G Abraldes  32 , Manuel Romero-Gómez  33 , Alexander Zipprich  34 , Meritxell Casas  35 , Helena Masnou  36 , Massimo Primignani  37 , Emmanuel Weiss  5 , Maria-Vega Catalina  3 , Hans-Peter Erasmus  38 , Frank Erhard Uschner  38 , Martin Schulz  38 , Maximilian J Brol  39 , Michael Praktiknjo  39 , Johannes Chang  39 , Aleksander Krag  40 , Frederik Nevens  16 , Jose Luis Calleja  15 , Marie Angèle Robic  14 , Irene Conejo  13 , Agustin Albillos  41 , Marika Rudler  10 , Edilmar Alvarado  9 , Maria Anna Guardascione  8 , Marcel Tantau  6 , Jaime Bosch  42 , Ferran Torres  43 , Marco Pavesi  5 , Juan Carlos Garcia-Pagán  4 , Christian Jansen  39 , Rafael Bañares  44 ; International Variceal Bleeding Observational Study Group and Baveno Cooperation
Affiliations
Free article
Observational Study

Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS

Jonel Trebicka et al. J Hepatol. 2020 Nov.
Free article

Abstract

Background & aims: The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date.

Methods: A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality.

Results: At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not.

Conclusions: This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB.

Lay summary: Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.

Keywords: Acute variceal bleeding; Acute-on-chronic liver failure; Cirrhosis; Rebleeding.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest Christophe Bureau has received speaker fees from GORE and is a board member of Alfawassemran/Norgine. Virginia Hernández - Gea, Álvaro Giráldez, Jaume Bosch, Agustin Albillos, Dominique Thabut, Michael Praktiknjo and Frederik Nevens have received speaker fees from GORE. Juan Carlos Garcia – Pagan has received consultant fees from GORE, Shionogi and Cook grants from GORE and Novartis. Jonel Trebicka has received speaking and/or consulting fees from GORE, Bayer, Alexion, MSD, Gilead, Intercept, Norgine, Grifols, Versantis, and Martin Pharmaceutical, and Rafael Bañares has received speaker fees from GORE and Grifols, unrelated to the submitted work. Please refer to the accompanying ICMJE disclosure forms for further details.

Comment in

Publication types

MeSH terms